Synopsis While manoeuvring to berth alongside the ferry wharf at Rivire-du-Loup on 04 June 1992, the passenger vessel GRAND FLEUVE, carrying approximately 400 passengers, struck the wharf. The striking resulted in minor damage to the vessel and minor injuries to four passengers. The Board determined that the GRAND FLEUVE struck the wharf as a result of the failure of the starboard main engine to respond to an order for astern propulsion. This failure was attributed to a vibration-caused electrical disconnection in the power supply to the servo-mechanism which controls the engine. 1.0 Factual Information 1.1 Particulars of the Vessel1 GRAND FLEUVE Official Number 811523 Port of Registry - Qubec, Quebec Flag - Canadian Type - Passenger vessel Gross Tons - 460 Length - 30.72 m Draught (at time of occurrence) F3: 1.52 m A: 1.74 m Built - 1989 Port Stanley, Ontario Propulsion - Two Cummins diesel engines, six cylinders, developing a total power of 597 kW, each driving a fixed-pitch propeller through a reversible reduction gearbox Owners - Les Investissements Navimex Inc. Qubec, Quebec 1 Because of major alterations made to the vessel shortly before this occurrence, some of the particulars no longer applied. However, at the time of the occurrence, no notice of alterations had been received by the Registrar of Ships. 2 Units of measurement in this report conform to International Maritime Organization (IMO) standards or, where there is no such standard, are expressed in the International System (SI) of units. 3 See Glossary for all abbreviations and acronyms. 4 All times are EDT (Coordinated Universal Time (UTC) minus four hours) unless otherwise stated. 1.1.1 Description of the Vessel The GRAND FLEUVE was built as a two-deck, twin-screw passenger vessel with a passenger capacity of 203. New owners purchased the vessel in March 1992 and immediately undertook several major alterations to increase her power and passenger capacity. At the time of the occurrence, the alterations had not yet been completed. 1.2 History of the Voyage The GRAND FLEUVE departed the Port of Qubec on 04 June 1992 with a crew of nine: a master, two officers and six persons who were working on the alterations and who were declared as crew by the owners. The vessel left the Louise Basin at 04304 and reported her departure to Vessel Traffic Services (VTS). She reported again when she passed St-Laurent, le d'Orlans, and Cap Brl. The GRAND FLEUVE docked at Cacouna, Quebec, at 1400 and remained there until 1540. The vessel did not inform VTS of either her arrival or her departure. After leaving Cacouna, the GRAND FLEUVE headed toward Rivire-du-Loup, Quebec. She reported to VTS as she passed le Blanche at about 1550, indicating that she expected to reach Rivire-du- Loup in about 15 minutes. VTS requested that she report on arrival. The GRAND FLEUVE docked at Rivire-du-Loup at about 1615 and immediately boarded about 400 passengers for an excursion to les du Pot l 'Eau-de-Vie, Quebec. During the boarding process, attempts by the steamship inspector to serve a detention order to the master in person were unsuccessful. The vessel departed Rivire- du-Loup as soon as the boarding was completed without informing VTS of either her arrival or her departure. Following a telephone conversation between VTS and the steamship inspector, VTS contacted the GRAND FLEUVE by very high frequency radiotelephone (VHF R/T) at 1642 and informed her that she was the subject of a detention order. The GRAND FLEUVE made some reference to orders having been received and advised VTS to refer the inspector to the owners in Qubec City. VTS made several other calls to the GRAND FLEUVE on channels 12 and 16 but received no response. After completing the trip to les du Pot l'Eau-de-Vie and while manoeuvring to berth, the vessel struck the Rivire-du-Loup wharf at 1805, sustaining slight damage to the port corner of the forward observation platform. Although four passengers were injured, the occurrence was not reported to the authorities. Not until 1810, after the passengers had disembarked the vessel at Rivire-du-Loup, did the GRAND FLEUVE resume radio communication. At that time, the vessel informed the ferry TRANS ST-LAURENT that she was departing Rivire-du-Loup. VTS took that opportunity to request the vessel's destination and to inform the vessel that the detention order had not been lifted. The GRAND FLEUVE responded that she was operating as a pleasure craft and had only crew on board. She then informed VTS that she had struck the ferry wharf, but neither damage nor passenger injuries were reported. The vessel continued to Qubec City and docked there at 0600, 05 June 1992. 1.3 Injuries to Persons The four injured passengers sustained their injuries when they fell while on the vessel's forward observation platform. 1.4 Certification 1.4.1 Vessel Certification Apart from a valid Radio Inspection Certificate issued on 03 June 1992, the GRAND FLEUVE did not have any of the certificates or documents required for a vessel of her size and type under the Canada Shipping Act or the regulations made pursuant to this act. Following the occurrence voyage, the GRAND FLEUVE was inspected by the Canadian Coast Guard (CCG), and a number of irregularities were found that affected the vessel's seaworthiness and compromised passenger safety. The shortcomings were later corrected, and the vessel was issued a provisional Steamship Inspection Certificate for a passenger vessel (SIC 16). The certificate increased her passenger capacity to 371 and assigned a temporary gross tonnage of 496.89 tons. 1.4.1.1 Passenger Vessel Status of the GRAND FLEUVE The owners maintained that the GRAND FLEUVE was operating as a pleasure craft, although she was carrying passengers at the time of the occurrence. This assertion was rejected by the CCG. The vessel was registered as a passenger vessel in 1989, and no change to that status had ever been requested or approved. 1.4.1.2 Alterations to the Vessel The major alterations being undertaken by the new owners were: installation of a new third engine; addition of a 10 m extension to the stern; and addition of a large observation platform overhanging the water at the bow. Work was started on these alterations before the plans were approved by the CCG. Although the inspection process had been initiated by the owners, many items were still unfinished at the time of this occurrence, and no inspection certificate had been issued. No sea trials were conducted. Standard-height railings along its perimeter constituted the only handholds provided on the forward observation platform. 1.4.2 Maintenance Records As the vessel had been decommissioned for over two years, there was no maintenance performed, nor were there any maintenance records on board. The current owners were the new owners of the vessel. Such vessels do not normally have formal maintenance records. 1.4.3 Personnel Certification and History The master held a Canadian Master Minor Waters Certificate issued in 1972. He had over 42 years' sea service. The chief officer held a Canadian Master Minor Waters Certificate issued in 1951. He had 50 years' sea service. The chief engineer held a Canadian Engineer Fourth Class Combined Certificate issued in 1991 and had completed a Marine Emergency Duties (MED) course. He had a total of 15 years' sea service and had been previously employed with the CCG for 13 years. 1.4.4 Crew Training As the GRAND FLEUVE is a passenger vessel of under 500 gross tons6, there is no regulatory requirement for her to carry lifeboatmen, nor is there a requirement for the crew to take a MED course. However, before a passenger vessel is issued a Steamship Inspection Certificate, the steamship inspector has to be satisfied as to the adequacy of the crew to handle the life-saving equipment involved and to safely evacuate the complement within 30 minutes. With the exception of the chief engineer, none of the crew aboard the vessel had taken a MED course. 1.5 Weather and Tidal Information At the time of the occurrence, skies were clear, wind and sea were calm, and visibility was good. These conditions were consistent with the forecast. High tide for Rivire-du-Loup was predicted to be at 1830. 1.6 Navigation Equipment 1.6.1 Vessel Equipment The navigation equipment in use was in good working order. 6 Gross tonnage of the vessel as indicated on SIC 16 (issued following the occurrence) governed regulations that then applied to the vessel. 1.6.2 Charts and Publications The GRAND FLEUVE carried all charts needed for the voyage, but no corrections had been entered on the charts since 1989. The vessel also carried some navigation publications, but no tide tables could be found. 1.7 Canadian Coast Guard (CCG) Action After several unsuccessful attempts to raise the GRAND FLEUVE on VHF R/T, VTS requested information about the vessel from a CCG helicopter that was operating in the vicinity. The pilot advised that he had seen the GRAND FLEUVE leaving Rivire-du-Loup with many people on board. 1.8 Life-saving Equipment There was insufficient life-saving equipment on board for the complement. When the vessel was inspected on 05 June 1992, she was carrying five 20-person liferafts and ten 25-person liferafts, for a total capacity of 350 persons. She also carried 273 lifejackets. 1.9 Vessel Stability On 01 June 1992, a stability test was carried out on the GRAND FLEUVE in the presence of a steamship inspector. The results of the test were submitted to the CCG for approval in June 1992, but approval had not been received by the end of the 1992 season. 1.10 Coasting Licence Because the GRAND FLEUVE was being operated for hire/reward, she was required to have a valid Coasting Licence issued by Canada Customs. Since no one had either applied for or received such a licence, the master was required to report to the nearest Customs office with proof of all relevant certificates. He had not done so. 1.11 Charter At the time of the occurrence, the GRAND FLEUVE was operating under charter to a group of conventioneers from Rivire-du-Loup. The contract had been signed at the end of February by the president of the group (charterer), who had relied on the owners'/tour boat operators' reputation and tourist information. The charterer expected the owners/operators of the GRAND FLEUVE to provide a properly certificated vessel and crew, thereby ensuring the safety of the charterer's membership (passengers). 1.12 Engine Controls Each engine is electrically controlled from the bridge by means of two servo-mechanisms, one controlling speed, and the other, the direction of the propeller thrust. The control system is powered by a single 12-volt DC power source. When the vessel was manoeuvring at the Rivire-du-Loup ferry wharf, the starboard engine failed to respond to an order for astern propulsion, and the vessel struck the wharf. Investigation revealed that the starboard engine servo-mechanism male/female electrical connector had become disconnected as a result of vibration during normal vessel operation. The male/female connector was of an inferior quality and was not provided with a locking device. The publication Ship Safety Electrical Standards (TP 127), under the heading Design of Equipment, outlines the CCG Ship Safety Branch requirement that: Machines and apparatus shall be so constructed that their efficiency is not impaired by vibration and shock likely to arise under normal service conditions; screws and nuts securing current carrying parts shall be of a type or provided with a device to prevent them from working loose due to vibration. The servo-mechanism had not been affected by the ongoing alterations. 1.12.1 Engines in Use Installation of the new centre engine was not yet complete. Only the vessel's starboard and port engines were in operation at the time of the occurrence. 1.13 Reporting Requirements The GRAND FLEUVE did not immediately report the occurrence involving passenger injuries to VTS as is required by the TSB Regulations. 1.14 Passenger Count The GRAND FLEUVE had no system for counting the number of passengers. Passenger figures in this report are therefore approximate only.